The severe pain struck when Christian Ortega’s lower left molars decayed, causing one molar to break. The pain was so bad that one day he had to skip his shift as a cook.

Lacking dental insurance, Ortega had previously scheduled an appointment at a Western Dental office, where he says the quote he was given to treat the decayed teeth was around $4,000, with a discount.

The 32-year-old Fresno father says he couldn’t afford to pay that amount, so he decided to forgo treatment.

“I was dealing with pain because I had no money to go and get it taken care of,” he said on a recent Friday morning after being treated at a free dental clinic in Fresno. The decay in Ortega’s molars had reached the nerve, which is what was causing the pain. A volunteer dentist, Daryl Ruby, took out Ortega’s nerve, filled the canals and then did a regular filing.

“As soon as the nerve is out, there’s no pain,” Ruby said.

While efforts to expand dental insurance rarely receive the same level of attention in the state as battles over universal medical care, the health implications are significant, experts say. An estimated 5.2 million Californians, representing 14% of the state population, lack dental benefits, according to the most recent data from the National Association of Dental Plans. That’s roughly double the rate of medically uninsured in the state, according to the 2017 California Health Interview Survey.

“It’s not a hot topic to talk about, and dental care is often a neglected topic, I think,” said Gabriela Ruvalcaba, executive director of the Sage Interactive Clinic in Indio, which provides free dental care. “But it is equally important.”

Although it can be tempting to skimp on dental care for those who lack insurance, untreated dental problems can lead to other health complications and higher medical costs, said Evelyn Ireland, executive director of the National Association of Dental Plans. A 2014 study by the group showed that when adult Medicaid recipients had preventive dental care, medical costs for seven chronic health conditions, such as diabetes and coronary heart disease, were lower by 31% to 67%.

“There are significant impacts to your overall health if you don’t take care of your oral health,” Ireland says. “We can’t say one causes the other, but we know … there’s a connection.”

The connection between oral and overall health seems to stem largely from bacteria and germs located in the mouth that can spread to other parts of the body and cause diseases, according to the Mayo Clinic. For example, “some research suggests that heart disease, clogged arteries and stroke might be linked to inflammation and infections that oral bacteria can cause,” according to the clinic.

People with gum disease have two to three times the risk of suffering a heart attack, stroke or other serious heart condition, according to Harvard Medical School. That, in turn, leads to increased costs and burdens on the medical system.

The effects also can go both ways. For instance, research has shown that diabetics are more susceptible to gum disease because diabetes reduces the body’s resistance to infection. Osteoporosis weakens bones, leading to periodontal bone loss and tooth loss.

Among emergency room visits from 2005 to 2016 that could have been avoided by access to quality care, an estimated 11% were for dental issues, according to a February study from the Public Policy Institute of California.

The problems can be particularly stark among seniors, who make up a disproportionately large share of the dental uninsured and are at greater risk for a range of health problems. According to data from Ireland’s organization and Medi-Cal, it is likely that as many as 2.5 million seniors in the state lack dental insurance, a number likely to rise because California is “experiencing significant growth in the senior population,” Ireland says.

One of the state’s 2.5 million seniors without dental insurance is Kai Kingsley of Palm Springs, a 72-year-old veteran who lives off Social Security and some money from selling his paintings. He recently visited Sage to have a tooth extracted and cavities filled.

“It was so painful and worrisome knowing I needed care but couldn’t afford no matter how much I saved up,” he said.

He donated a painting to the clinic to show his thanks. It now hangs in the center of the office.

After seniors, most of the remaining uninsured are likely people working for small to medium-sized businesses that don’t offer such benefits, Ireland said. In California, people working for small businesses that don’t offer dental benefits can choose to buy individual plans through Covered California or directly from other carriers.

But with no individual mandate requiring people to obtain dental coverage, she said, some individuals may decide they don’t have the disposable income to purchase a plan.

“You have to pay for everything that comes with, you know, life,” he says, adding that food, rent, bills and other essential necessities come first.

In fact, he says, he had only seen a dentist twice before in his life. Those two times were to have a tooth extracted.

When the third time came around and he got the $4,000 quote, he and his wife found the amount to be out of their reach.

But through a relative, he recently found out about Saint Agnes Medical Center’s Holy Cross Clinic. The clinic, which offers free dental and medical care, operates out of the Poverello House, a homeless shelter in Fresno.

Ruby, 77, the volunteer dentist who treated Ortega, estimates that the dental procedures he performed were worth around $2,000.

Ortega wasn’t required to pay anything, though he did leave a donation.

“My pain is gone. Perhaps, the most important thing, I can go back to work,” said Ortega.

Ortega is far from alone among Americans who skip dental care for cost reasons. An April research brief by the Health Policy Institute found that, from 2013 to 2016, over 15% of the U.S. population reported not getting the dental care they needed in the previous 12 months.

The top three reasons respondents gave were not being able to afford it; the procedures weren’t covered by their insurance; and people did not want to spend the money that was required.

“A lot of patients don’t have a lot of money and are living check to check, and yet so often many of our patients bring us food as a thank you because they just never thought they could get help before,” Ruvalcaba, of the Indio clinic, said.

The clinic, founded by longtime dentist and outreach worker Javad Aghaloo, has served dozens of uninsured patients since opening in February, she said. Aided by grants from the HN Berger Foundation and Delta Dental Foundation, Sage has a staff of eight, including dentists and office staff. Other dentists either volunteer their time or are residents completing their training.

At the Holy Cross Clinic in Fresno, patients also leave whatever they can, said office coordinator Crystal Correa. Saint Agnes Medical Center, through its charity work, contributes to help run the clinic.

The eight dentists and one hygienist all are volunteers.

Through May, the clinic had served 302 patients over the preceding 12 months.

“We don’t turn anyone away,” Correa said.

Bertha Gonzalez, who has been assisting the volunteering dentists for almost 15 years, says that in addition to patients without any coverage, the clinic sees patients with Medi-Cal and other insurance who can’t afford their high copays or other out-of-pocket costs.

The minimum bill an uninsured person would have to foot for a root canal is around $1,500 -- that could be a person's monthly salary, says Megha Sata, dental director at Care Harbor, which provides free medical, dental and vision clinics to thousands of uninsured, underinsured and underserved people in stadiums and large venues across the state and the nation. And the costs could easily go up to $2,000 to $2,500, according to various estimates.

“Cost is definitely the biggest issue for people who don’t have coverage,” Sata says.

When Care Harbor hosts its free clinics, dental care is the “number one need,” says Don Manelli, the provider’s president.

“We see some pretty advanced cases,” he says.

Camille Nishikawa, clinical assistant professor at the Herman Ostrow School of Dentistry at the University of Southern California, said the unmet need is great. The various programs under the dentistry school served over 40,000 patients with free or low-cost dental services last year alone.

The value of those services is well over $1 million. The USC mobile dental fleet is the largest civilian fleet in the nation, Nishikawa said.

In addition, the California Dental Association organizes two large free dental clinics a year, each serving an average of nearly 2,000 people. During its most recent event at the Solano County Fairgrounds in Vallejo in March, it provided $1.3 million in free dental services. The next free dental clinic will take place at the National Orange Show Events Center in San Bernardino in the fall.

The clinics are funded by the California Dental Association, as well as through donations from corporate sponsors, grants and individual donations, according to the association.

But the need is not only among those without dental coverage. Although more than 12 million Californians receive dental insurance through the state’s Medicaid program, Medi-Cal, and the Children’s Health Insurance Program (CHIP) for low-income residents, some are not aware that their medical coverage also includes dental benefits.

Dental benefits for adults were fully restored to Medi-Cal enrollees last year after being cut in 2009 and partially restored in 2014.

Juan Sevilla, 66, says he didn’t know that his Medi-Cal benefits also included dental care.

On a recent Friday, he made his fifth or sixth visit to the Holy Cross Clinic in Fresno.

“I had pain,” he said in Spanish.

Sevilla had a decayed tooth removed, among other dental procedures.

All Medi-Cal adult recipients were informed when the dental benefits were reinstated, said Anthony Cava, spokesman for the California Department of Health Care Services.

But even those who know about their benefits often have a difficult time accessing care because it’s difficult to find dentists who accept Medi-Cal, Sata and other experts said.

In October, the state announced that it would put more than $500 million toward increasing reimbursement rates for Medi-Cal dental services, and make it easier for dentists to become providers.

As part of efforts to bring awareness to people about their dental coverage, the state has established the Dental Transformation Initiative and Smile California to raise awareness about Medi-Cal dental benefits and promote coverage, Cava said.

But only a fraction of the money the state spends on Medi-Cal outreach efforts goes specifically to the program’s dental component.

The state spent a total of $761,222 in fiscal year 2018-19, and less than $200,000 the previous fiscal year, on Medi-Cal dental outreach, according to figures from the state’s Department of Health Care Services. In comparison, it spent $27 million from fiscal year 2013-14 to 2017-18 for general Medi-Cal outreach. The $27 million funding came in part from The California Endowment, which was matched by federal dollars.

The state also continues to reach out to non-enrolled dental providers, especially those in underserved counties, to encourage them to participate, Cava said.

Ruby said when he had his private practice, he wouldn’t take Medi-Cal and Medicare patients because the reimbursement rate was so low.

“I’d rather come down here and do dentistry for free than fight out the bureaucracy … to get paid,” he said.

HOW TO ACCESS DENTAL CARE

If you have Medi-Cal, you already have dental coverage through Denti-Cal. Check with your dentist to see if they accept Denti-Cal or visit http://smilecalifornia.org/ or call 1‑800‑322‑6384 to learn more.

About This Series

This project results from an innovative reporting venture – the USC Center for Health Journalism News Collaborative – which involves print and broadcast outlets across California, all reporting together on the state’s uninsured. Outlets include newspapers from the McClatchy Corp., Gannett Co., Southern California News Group, and La Opinion, as well as broadcasters at Univision and Capital Public Radio.